Provider Demographics
NPI:1316336795
Name:LUBSEY MEDICAL CLINIC INC
Entity type:Organization
Organization Name:LUBSEY MEDICAL CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KHALIL
Authorized Official - Middle Name:H
Authorized Official - Last Name:ODEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-438-6666
Mailing Address - Street 1:5300 W VILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-4345
Mailing Address - Country:US
Mailing Address - Phone:414-438-6666
Mailing Address - Fax:414-438-6667
Practice Address - Street 1:5300 W VILLARD AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-4345
Practice Address - Country:US
Practice Address - Phone:414-438-6666
Practice Address - Fax:414-438-6667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24166174400000X
WI61393174400000X
207R00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty